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According to a new study published in Cancer Prevention Research (June 8th, 2015), prostate cancer survivors who consume a typical Western diet consisting of red meat, refined grains, processed foods and high-fat dairy products may be at an increased risk of death from recurrent prostate cancer as well as other causes. Researchers at Harvard T.H. Chan School of Public Health studied 926 men aged 40 to 84 who were diagnosed with prostate cancer that had not spread. Subjects answered questions about their diets five years after receiving a prostate cancer diagnosis and were monitored for approximately 10 years. The men diagnosed with non-metastatic prostate cancer who ate a diet that was more Westernized were 2.5 times more likely to die of prostate cancer than those who ate the healthiest diet and 1.5 times more likely to die of any cause. The healthiest diet was a Mediterranean-style diet rich in fruits, vegetables, and fiber with fewer dairy products and less red meat. The researchers concluded that their “results suggest that the same dietary recommendations that are made to the general population primarily for the prevention of cardiovascular disease may also decrease the risk of dying from prostate cancer among men initially diagnosed with non-metastatic disease.”
The following article dated August 6th came from a site entitled Prostatesnatchers authored by a noted prostate oncologist, Dr. Mark Scholz. He suggests that a commercial OPKO-4Kscore blood test and a high-resolution color Doppler ultrasound or a 3-Tesla multi-parametric MRI can help identify aggressive cancers and minimize the use of standard 12-core prostate biopsies and their potential side effects. The OPKO-4Kscore blood test is comprised of measurements of total and free PSA coupled with proprietary tests for intact PSA and a panel of four kallikrein (a specific group of enzymes) blood markers. My own prostate oncologist commented favorably on this test. “It won’t be the last word, but it is a productive departure from single-lab-value (PSA) technology, which is over 30 years old.” Remember the contents of this website are not intended as personal recommendations but the potential use of this information should be discussed with your personal physician. You should also check on the cost and insurance coverage of the tests described below.
“You PSA is elevated. Now your doctor recommends a needle biopsy, 12 cores through the rectum to check for cancer in the prostate. Sounds icky, but also logical; after all who wants to miss cancer? But come on, do you really have to do 12 stabs via the rectum?
Each year over a million men submit their prostates for a biopsy. At an average cost of around four thousand dollars, the prostate biopsy business is a 4-billion-dollar-a-year enterprise. But it’s not merely the cost that gives pause. Three percent of men end up hospitalized with life-threatening infections. Around a 100,000 men every year get a confounding diagnosis of Grade 6 prostate cancer, a truly harmless entity, unless you get suckered into an unnecessary radical prostatectomy.
Obviously, prostate biopsy is an unpleasant proposition with notable risks. However, ignoring a high PSA incurs the risk of missing a diagnosis of a higher grade prostate cancer. As things stand now, of the million biopsies being done annually, over a hundred thousand men with Grade 7 or higher cancers are being detected. For these men, their early diagnosis is beneficial, leading to early, curative treatment in a timely fashion.
How can we detect the 100,000 men with higher-grade cancers that need to be detected without doing 900,000 “unnecessary” biopsies? The answer to this question continues to evolve as technology marches forward. Our latest thinking at Prostate Oncology (assuming the PSA is not wildly elevated, say over 20) is a three step process:
1. Simply repeat the PSA to confirm it is indeed abnormally elevated. All sorts of things can cause temporary elevations of PSA ranging from nonspecific inflammation of the prostate, to recent sexual activity, to simple laboratory errors.
2. If the PSA remains elevated with repeat testing the next step to consider is an OPKO-4Kscore blood test. The OPKO test reports a percentage estimate of the likelihood of higher grade cancer being present. The test is not perfect, but it performs pretty well. For example, if a specific patient receives an OPKO report with an estimated risk of high grade disease of less than 15%, a standard random biopsy (if he elected to do one) will confirm the absence of high grade disease 92% of the time. Not bad.
3. Our next step at Prostate Oncology in the cases where a patient has an OPKO test indicating that the risk of high grade disease is over 15%, is to obtain a prostate scan with high-resolution color Doppler ultrasound or with a 3-Tesla multiparametric MRI. With scanning, the location of the high-grade disease can be determined over 90% of the time so that a targeted biopsy with 2 or 3 cores can be substituted for the traditional 12-core biopsy.
The business of prostate biopsy has become so out of control the US Preventative Services Task Force advocates against PSA testing altogether. The Task Force’s scientifically-based arguments that PSA testing is causing more harm than good are really quite convincing. However, back in 2011 when they published their recommendations, the OPKO test and 3-Tesla multiparametric prostate MRI were unavailable. With the advent of these new technologies, PSA screening to detect higher grade prostate cancers at an early stage when they are still curable makes perfect sense.“
In a recent interview, Dr. Mario Eisenberger, Professor of Urology and oncology at Johns Hopkins, summarized a group of on-going clinical trials for patients with metastatic, hormone-resistant prostate cancer. Trials are ongoing combining agents targeting the androgen receptor such as abiraterone (Zytiga®) with chemotherapies such as docetacel® (taxotere) or cabazitaxel (Jevtana®). Other trials such as the Alliance trial, combines abiraterone with enzalutamide (Xtandi®). An on-going phase III trial combines abiraterone with radium -223 (alpha-radin, Xofigo®) in men with metastaic disease who have not received chemotherapy. Dr. Eisenberger states that there are a number of trials combining approved drugs with chemotherapy and hormonal therapy and radiopharmaceuticals such as radium-223. There are also trials using combinations of PARP inhibitors (s0 far un-approved for prostate cancer) with standard, second line hormonal therapies. Also there are antitumor PI3K and AKT inhibitors some of which inhibit more than one pathway which are over-expressed in prostate cancer patients who progress on androgen receptor-targeted compounds such as abiraterone or enzalutamide. The question is whether PI3K or AKT inhibitors will enhance the effects of abiraterone or enzalutamide. Dr. Eisenberger also discusses trials involving approved agents for metastatic disease as well as unapproved agents like TAK-700 (Ortoronel®) and ARN509 being tested in men with metastatic, hormone-naive cancer. In addition, chemotherapy trials such as CHAARTED and STAMPEDE are discussed. This post is primarily aimed at physicians. If you are a patient with metastatic disease, I suggest you discuss these trials with your physician to see if any one would apply to your specific situation.
The book of James 1-24 state: “2 Consider it all joy, my brethren, when you encounter various trials, 3 knowing that the testing of your faith produces endurance. 4 And let endurance have its perfect result, so that you may be perfect and complete, lacking in nothing.”
Prostate issues such as cancer are indeed troublesome trials. Are you wasting your troubles? Any time God allows trials to enter your life, He has a purpose for them. He wants you to squeeze out every ounce of spiritual growth instead of letting difficulties force you into despair and discouragement. If you’ll just respond in the right manner, the trial that looks as if it could destroy you becomes an instrument of blessing.
The most natural response to adversity is to groan and plead with the Lord to remove it. If that doesn’t work, we might get angry and say “why me?” But in truth, ultimately God allowed it. No matter where affliction originates by the time it reaches you, it’s been dipped in the Father’s love and shaped to accomplish His good purpose. The question is, will you cooperate with Him, or will you resist?
Perhaps the key word is found in verse 4 of the verses above. God wants to use our trial to develop spiritual maturity, but unless you let it do its work, that opportunity will be lost. If we could foresee every benefit the Lord designed our trials to accomplish, maybe we’d be more cooperative.
Although we can’t see all the specifics of God’s plan, we know that His goal is to use our adversity to supply something we lack so we can be mature and complete. Even though the experience is painful, rest in the Father’s comforting arms, and let Him do His perfect work in you.
If you are not sure how these scriptural truths can apply to you, or if you are not sure whether or not you have a personal relationship with God through His Son, Jesus Christ, please see the following linked website section.
The above message was excerpted and adapted from the In Touch devotional by Dr. Charles Stanley, August 17th, 2015.
Two recent reviews have been published in Oncology describing the history, developmental clinical study results, treatment optimization and future directions for radium-223 chloride in prostate and other cancers. It should be noted that these articles are primarily written for physicians and health care providers. See the accompanying links.
Radium-223 chloride (alpha-radin) is an alpha-particle- emitting radiopharmaceutical which is specifically taken up by bone cells (osteoblasts). These high energy alpha particles with short tissue penetration range allow for targeted prostate cancer cell killing with low toxicity. Improvement in overall survival and relief of skeletal symptoms have been demonstrated in prostate cancer patients who are hormone resistant and have multi-focal symptomatic bone metastases.
The following is an excerpt from In Touch Devotional, Friday July 17th, 2015 written by Dr. Charles Stanley, Pastor of the First Baptist Church of Atlanta.
“It doesn’t seem fair, does it? The apostle Paul spent the second half of his life serving Christ, yet he experienced continual suffering.” 2 Corinthians 11:23-30 state that Paul was beaten multiple times, shipwrecked three times, stoned, robbed, experienced hunger, thirst, cold, exposure to the elements, and countless dangers. Yet he didn’t boast about his bravery but instead his weaknesses. He then countered with the statement, “when I am weak, then I am strong” (through his relationship with Christ). “Why would God let one of his most faithful servants go through so much pain? This isn’t a question just about Paul; it’s an issue we face today. In our minds, the Lord should protect His loyal followers from hardships” (e.g. prostate and other cancers and diseases) “but He doesn’t necessarily do so.
Maybe our reasoning is backwards. We think faithful Christians don’t deserve to suffer, but from God’s perspective, suffering is what produces faithful Christians. If we all had lives of ease without opposition, trials or pain, we’d never really know God, because we’d never need Him. Adversity simply teaches more about the Lord than simply reading the Bible ever will.
I’m not saying we don’t need to know Scripture; that’s our foundation for faith. But if what we believe is never tested by adversity, it remains head knowledge. How will we ever know that God can be trusted in the midst of trouble if we’ve never been challenged by hardship? The Lord gives us opportunities to apply scriptural truths to the difficulties facing us, and in the process, we find Him faithful. For example, how would Paul ever have known the strength of Christ if he had never been weakened by persecution, pain and adversity?
Depending on your response, trials can be God’s greatest means of building faith or an avenue to discouragement and self-pity. If you’ll believe what Scripture says and apply its principles to your situation, your trust in God will grow and your faith will be strengthened through adversity.”
If you are not sure of your relationship with God through Christ, or want to know more about having one, see the following website link.
In a follow up to earlier website posts, British researchers have found that starting the chemotherapy drug docetaxel® at the same time as hormone therapy can improve survival for men with newly diagnosed, advanced prostate cancer. The full article describing the study was published in the Prostate Cancer Foundation June 1 issue of NewsPulse. Currently, chemotherapy is generally given after hormone therapy stops working. But the new study found that when the two therapies were paired at the start of treatment, patients lived an average of 10 months longer. The combination had even greater benefits for men whose prostate cancer had spread to other parts of their bodies — known as “metastatic” cancer. These men experienced an average 22-month improvement in their overall survival, the findings showed. Men treated with hormone therapy alone lived an average of 67 months. Those treated with docetaxel® and hormone therapy ended up surviving an average of 77 months, a relative improvement of 24 percent. Those with invasive prostate cancer survived an average 65 months when they received docetaxel® and hormone therapy together, compared with 43 months for men who received just hormone therapy, the investigators found. The chemotherapy drug appeared to benefit men by holding their cancer at bay. Docetaxel® extended the time to relapse by 38 percent in all patients. Hormone therapy can cause fatigue, anemia, brittle bones, decreased muscle mass and loss of sexual function, while chemotherapy drugs open the body to a host of debilitating side effects. But the researchers noted that the addition of chemotherapy to hormone therapy in this study was well-tolerated. Very few men dropped out due to side effects from the chemotherapy, they added. The researchers state that is hoped that these findings will encourage doctors to offer docetaxel® to men newly diagnosed with metastatic cancer.
A new study suggests that adding radiation therapy to hormone therapy improves the chances of survival for men with prostate cancer that has spread to nearby lymph nodes. Investigators at Massachusetts General Hospital’s Cancer Center focused on 318 patients treated with hormone therapy alone and 318 who received hormone therapy and radiation therapy. The five-year death risk among those who received the combination therapy was 50 percent lower than among those who received hormone therapy alone, the findings showed. The study was published online May 11 in the Journal of the National Cancer Institute. A summary was published in the Prostate Cancer Foundation June NewsPulse. “It appears that more aggressive local management of prostate cancer confined to the pelvis can offer more durable disease control, prevent the disease from spreading further and, for some patients, even provide a potential cure,” senior study author Dr. Jason Efstathiou, of Massachusetts General Hospital’s Cancer Center and department of radiation oncology, said in a hospital news release.
The self-adjuvanted RNActive vaccine (CV9103) appears to be well-tolerated and immunogenic in men with advanced castration-resistant prostate cancer, according to a new phase I/IIa study. German researchers have been studying this new vaccine approach and they believe it has the potential to improve outcomes in men with resistant disease.
CV9103 is a sequence-optimized, chemically unmodified mRNA immunotherapy targeting four antigens: prostate-specific antigen (PSA), prostate-specific membrane antigen (PSMA), prostate stem cell antigen (PSCA), and six-transmembrane epithelial antigen of the prostate 1 (STEAP1). These antigens are frequently and almost exclusively expressed in the prostate and over-expressed in prostate cancer. However, they noted that PSMA is also over-expressed in other cancers. These antigens were picked for the vaccine because they are mainly found on residual prostate cancer cells after radical prostatectomy or radiation. German researchers conducted a study with CV9103 in 44 patients with advanced castration-resistant prostate cancer. The primary endpoint of the study was safety and tolerability, and the secondary endpoints included induction of antigen specific immune responses monitored at baseline and at weeks 5, 9, and 17. Of the 33 evaluable patients treated at 1280 μg, a cellular immune response could be detected in 76% of the patients (n= 25). The researchers, who published their findings in the Journal for ImmunoTherapy of Cancer, found that immune responses against all four antigens could be induced, indicating the versatility of the platform. The study demonstrated that CV9103 was well-tolerated and the majority of treatment-related adverse events were mild to moderate.
“The data generated by this phase I/IIa clinical study demonstrate that CV9103 mRNA was well-tolerated and immunogenic. Furthermore, a trend towards longer survival time was also observed in immune responders,” said senior author of the paper Arnulf Stenzl, MD, who is the Medical Director of the Department of Urology, University of Tübingen Medical School, Tübingen, Germany. “Based on these results, it is evident that this mRNA technology warrants further clinical investigation.” The researchers are now conducting a randomized, placebo-controlled, phase IIb study in 197 prostate cancer patients with the next generation experimental vaccine CV9104. This second vaccine (CV9104) targets six antigens, including the additional antigens prostatic acid phosphatase (PAP) and MUC1.
When men are newly diagnosed with prostate cancer, they are split into three broad categories: Low-Risk, Intermediate-Risk and High-Risk. This system, which was invented by Dr. Anthony D’Amico, is helpful for the proper selection of optimal treatment; men with more favorable types of prostate cancer can receive milder therapy and still maintain normal survival rates. In a recent e mail message from prostatesnatchers, below) these categories are defined and appropriate therapeutic options given. A major conclusion cited is that “the cancer of men with the favorable type of Intermediate-Risk prostate cancer behaves the same as Low-Risk. Analysis provides further clinical evidence that men with the favorable type of Intermediate-Risk prostate cancer can forego immediate radical therapy and embark on active surveillance.”
As far as treatment selection is concerned, as a general rule of thumb, men with Low-Risk disease are encouraged to simply monitor the disease, withholding therapy altogether unless tumor growth is detected on subsequent testing. At the other extreme, men with High-Risk disease typically undergo combination treatment with three forms of therapy: seed radiation, IMRT and hormone therapy, which is continued for a year and a half.
Treatment recommendations for men with Intermediate-Risk range widely from surgery, to the many types of radiation—IMRT, seed implants, SBRT and Proton therapy to focal therapy, as well as the alternative of simply giving hormone therapy by itself. This wide variety of treatment options is not merely a result of physician bias. It turns out that the types of cancer that occur in the Intermediate-Risk category also vary widely. At the “good” end of the spectrum, men with the favorable type of Intermediate-Risk disease have a condition that behaves more like Low-Risk while cancers men at the unfavorable end of the Intermediate-Risk spectrum have a condition that behaves more like High-Risk.
The indicators that define an unfavorable type of Intermediate-Risk disease are multiple intermediate characteristics rather than having a single Intermediate-Riskfactor. For example, it is considered unfavorable when the PSA is over ten and the Gleason is 4 + 3 (instead of 3 + 4) and there are more than 50% of the biopsy cores containing cancer. At the other extreme are men with the favorable type of Intermediate-Risk disease. These men are characterized by having all the Low-Risk factors in combination with only a single Intermediate-Risk factor.
Making a proper distinction between the favorable and unfavorable types of intermediate risk disease can be monumentally important as it relates to treatment selection. Studies show that men with favorable Intermediate-Risk disease are potential candidates for active surveillance. A recently published report at this year’s Genitourinary ASCO meeting bears directly on this issue:
In an abstract from the ASCO meeting authored by Ann Caroline Raldow from Harvard, 6500 newly-diagnosed men treated with radiation and hormone therapy at the Chicago Prostate Cancer Center between 1997 and 2013 were evaluated. Dr. Raldow calculated their survival rate after treatment based on their risk category: low, favorable-intermediate, unfavorable-intermediate, and high. Eight years after treatment 820 men had died, 72 of them from prostate cancer. Men in the favorable Intermediate-Risk category had the same survival rates as men in the Low-Risk category. Men in either the High-Risk category or in the unfavorable Intermediate-Risk category demonstrated an increased mortality rate from prostate cancer.
Bottom line, the cancer of men with the favorable type of Intermediate-Risk prostate cancer behaves the same as Low-Risk. Dr. Raldow’s analysis provides further clinical evidence that men with the favorable type of Intermediate-Risk prostate cancer can forgo immediate radical therapy and embark on active surveillance.